It’s Friday, it’s 10PM, your shift is ending in an hour and the weekend beckons. The medic phone rings, they’re bringing you an obese man with a poly-drug overdose; nortryptilline, diazepam, venlafaxine, and trazadone. They tell you that the patient is sleepy with a lowish BP of 100/60 but seems okay.
5 minutes later the medics crash through the door, the patient is totally flat on the gurney, they are bagging him but can’t get effective air movement, the patients nose and fingers are somewhere between purple and black in colour. ‘Respiratory collapse in the car doc!’ the medic shouts, ‘I can’t bag him!’ The patient looks to be about 5’7″ and you estimate a weight of about 400lbs. His neck is short to the point of being non-existent. What do you do now?
The crash difficult airway is a not-uncommon scenario in the emergency department. This presents us with the absolute worst airway situation; the patient is hypoxic and near to death, the airway is difficult and we have had no time to prepare for a nuanced attempt at airway management. We all know by looking at this patient with a BMI above 40 and no neck that the airway is going to be a challenge, and that cricothyrotomy will be equally or more difficult.
Different providers in different specialties have different approaches to this sort of scenario, here’s what I do.
Step 1 in the management of this patient is to recognize the nightmarishness of the situation and put out an overhead call for help. Unfortunately in many community hospitals on a Friday evening there may be no other doctors around to join you on your sinking ship.
Step 2 is to temporize. You must improve the patients oxygenation by any means necessary to prevent imminent death. In an obese patient like this one sit the patient up and try a BVM breath with one person dedicated to holding the mask and another to bagging. If you are able to move air you will likely be able to reoxygenate the patient this way and allow yourself a reasonable attempt at intubation. If you are unsuccessful at moving air you should place a supraglottic device. My personal preference is an intubating LMA.
The LMA can be placed quickly and easily and with no need to visualize the difficult airway at all. It offers an excellent chance of successfully reoxygenating the patient. The intubating LMA allows subsequent definitive control of the airway and is easy to use with a little practice.
Step 3, by now hopefully the patient is reoxygenated and the acral areas are fading from black to purple to blue to pink. I personally use video laryngoscopy for the majority of my intubations and that would be my first choice here. Patients with overdose have a tendency to vomit during intubation and I prefer to intubate them in the seated position to try to minimize this risk. It is not uncommon in a patient like this to get a decent epiglottis view and a partial cords view but have a difficult time passing the tube. If this happens I would suggest passing a bougie under direct visualization and then passing the tube over-top (also under direct visualization).
Step 4 is when all of the above fails you must do a surgical airway. No one will want to do a surgical airway in this patient, it will be difficult, but if your supraglottic devices and intubation attempt have failed it needs to be done. The worst thing that could happen to a patient like this is repeated futile attempts at intubation once that option has failed. If you need step 4 use your ultrasound to find the trachea and cut, and know that your weekend is probably shot.
If anyone else has a different approach please share it in the comments section!